Patients suspected of having coronary artery disease (CAD) underwent dipyridamole thallium scintigraphy, exercise electrocardiography, and coronary angiography. Of the 500 patients studied, 163 were at least 65 years old, and 337 were less than 65 years old. Both CAD and multivessel CAD were more common in elderly than in younger patients (81% vs 69%, p<0.01 for CAD; and 43% vs 26% p<0.01 for multivessel CAD). In patients without myocardial infarction, the specificity of exercise electrocardiography was lower among elderly patients than among younger patients (52% vs 61%), but the sensitivity was higher (87% vs 75%). In contrast, both the sensitivity and the specificity of dipyridamole thallium scintigraphy were similar in the two age groups (86% vs 87% and 79% vs 74%). Among patients with myocardial infarction and a positive exercise test, reversible defects were equally common in the two age groups (60% vs 58%). The reversible defects were in areas remote from the area of infarction in half of the patients in both groups. Among patients with negative exercise-test results, reversible defects were more common in elderly patients than in younger patients (57% vs 38%). The reversible defects were in the infarcted area in 71% and 79% of these patients, respectively. These results indicate that dipyridamole thallium scintigraphy is a sensitive and specific method for detecting CAD, independent of age. It is particularly useful in identifying myocardial viability in the infarcted area.
I examined the characteristics of Helicobacter pylori (H. pylori) infection in elderly patients with peptic ulcer and its relation to the endoscopic appearance of the gastric mucosa. 1) Infection with H. pylori was more common in middle-aged patients (those over 40 and younger than 59 years old, 80.4%) than in younger patients (those less than 39 years old, 63.0%). Elderly patients were less likely than younger patients to be infected (60's: 77.7%, 70's: 70.8%, over 80 years old: 65.8%). The percentage was higher in men than in women, in all age groups. 2) Oshima's classification was used to divide the patients into 5 groups, according to the endoscopic appearance of blood vessels of the gastric mucosa. Infection was found in 71.7% of the patients without atrophy, in 86.3% of those with mild atrophy, and in 88.9% of those with moderate atrophy. In contrast, infection was found in only 78.4% of the patients with severe atrophy. Similar results were found in patients with peptic ulcer and in subjects with no lesion except atrophic gastritis. 4) The percentage of patients with gastric ulcer disease who had atrophic gastric mucosa was higher in those with ulcers above the middle of the stomach (46.3%) than in those with ulcers in the antrum (30.2%, p<0.05). Almost all patients with gastric ulcers in the lower part of the stomach and in the angulus were found to be infected with H. pylori (93.3% and 94.0%, respectively). The percentage of patients with ulcers low in the stomach who were infected was lower (59.4%). All of the location-related differences in infection were significant (p<0.001).
The Guidelines on Treatment of Hypertension in the Elderly, 1995 was published by the Research Group for Guidelines on Treatment of Hypertension in the Elderly Comprehensive Research Projects on Aging and Health, the Ministry of Health and Welfare. To assess the guidelines, and to further investigate the changes in the therapeutic policy for hypertension in the elderly, we mailed a questionnaire to 133 Japanese hypertension specialists who had replied to the first mailed questionnaire in 1993. We received 102 replies (77%). Overall, the guidelines were scored 4.3/5.0. More than 95% of the specialists agreed with levels of blood pressure (BP) indicative for treatment, as well as the goal of BP control. The guidelines propose that the rate of increase of the drug dose should be very slow, at least every four weeks, and that the target BP be reached after two months. The majority of the specialists agreed with this. However, 10% of them preferred to follow patients every two weeks. The guidelines propose long-acting Ca antagonists and ACE inhibitors as the first choice of drug for the treatment of uncomplicated hypertension in the elderly. Two-thirds of the specialists agreed. However, 17% of specialists proposed adding diuretics or β-blockers to the first line therapy. Ten specialists (10%) expressed concerns about Ca antagonists and three (3%) insisted on withdrowing them from the first line of drugs. In the guidelines, α and β blockers are designated as relatively contraindicated in elderly patients with hypertension, but half the specialists answered that these drugs can be used safely in elderly patients. These findings indicate that the therapeutic policy of Japanese specialists in hypertension in the elderly has not changed substantialy for three years.
The purpose of the present study was to clarify the deterrent factors for rehabilitation training (rehab) of chronic cerebral vascular disease (CVD) patients, and also to evaluate the influence of age on these factors. Sixty-five CVD impatients with sequelae treated at the Cerebral Vascular Center of Nanasawa Hospital were included in the study. Patients were classified into two groups using the Barthel index score: good effect group (n=21) or no effect group (n=22). The following factors were compared between the two groups in order to investigate which factor most affects the results of rehab: age, sex, the site of brain damage, extent of motor paralysis, character (Type A character or not), aphasia, hemispacial neglect, depression, and positive attitude toward training. A possible association between depression, and the site of brain damage and Type A character was investigated. Also, the difference in mood disorders was compared between elderly and non-elderly stroke patients. In the elderly group, hemispacial neglect, a negative attitude toward training, and depression all adversely affected the outcome of the rehab. In the non-elderly group, aging, hemispacial neglect, and a negative attitude toward training influenced the effect of the rehab, but there was no correlation with depression. Depression was seen in 64% of the patients (38/59). Of the 38 patients in a depressed state, 24 (63%) had right hemisphere brain damage, 13 (34%) had left hemisphere brain damage, and 1 (3%) had brain stem damage. Twenty-seven of the 38 depressed patients (71%) were Type A character, significantly more than in the non-depressed group (92/21, 43%). In addition, 14 of the 27 Type A patients were aged over 65 years (52%), which was more than in the non-depression group (11/38, 29%).
We performed endoscopic injection sclerotherapy (EIS) for esophageal varices on approximately 214 patients between October 1981 and July 1994 at our hospital. Of the 214 patients 114 have died, and we divided them into two groups according to their age when EIS was first performed: (i) group 1, less than 70 years old; and (ii) group 2, more than 70 years old. We investigated the efficacy of EIS for the group 2 patients with esophageal varices by comparing the two groups. EIS was considered effective in the group 2 patients because there was no difference between the two groups in the period of observation after EIS, but the time to re-therapy in the autopsy cases of this age group was significantly less. As a result of investigating the surgical outcome and the direct cause of death, it was suggested that; in future, prevention of death by hepatocellular carcinoma and hepatic failure was necessary for both groups.
The combination of ataxia with peripheral neuropathy (ataxic neuropathy) is rare. Six elderly patients with peripheral neuropathy who developed ataxia were studied. Of the peripheral neuropathies, ataxic neuropathy was significantly more frequent in patients aged more than 65 years compared with younger patients. Ataxic neuropathy was associated with carcinoma (2 cases), Sjögren's syndrome (1 case), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP, 1 case) and chronic idiopathic ataxic neuropathy (2 cases). The two cases of carcinomatous neuropathy initially showed ataxia, which preceded detection of the carcinomatous lesions in the lung by approximately 1 year. The study cases had many clinical features in common. In the nerve conduction study, sural nerve action potential could not be measured in five of the cases; sural nerve biopsy revealed a decreased density of myelinated fibers in all cases. In particular, the large myelinated fibers were markedly decreased. These findings were common, regardless of the underlying disease, except in the case of CIDP in which there was only a slight decrease in the number of large myelinated fibers. Differential diagnosis based on the clinicopathological features was difficult. Therefore, in cases of ataxic neuropathy, systemic evaluation is necessary to rule out the possibility of carcinoma or various systemic diseases, especially in elderly patients.
We studied the relation between performance of activities of daily living and X-ray findings of osteoarthritis of the knee in aged persons. We made Covariance Structure Analysis models of knee pain, X-ray findings and bone mineral density as measured by computed X-ray densitometry. The subjects were 257 women aged from 47 to 88 years who were outpatients at an orthopedic clinic. The best-fit model indicated that loss of bone mineral density in metacarpals was associated with X-ray findings of knee-joint degeneration, as well as with knee pain. No relationship was found between knee-joint degeneration and knee pain. These results suggest that bone mineral density should be taken into consideration when interpreting X-ray findings of knee pain. This model incorporates the effects of degeneration of the subchondral bone. In summary, we should use measurements of bone mineral density along with X-ray findings for the diagnosis and treatment of knee osteoarthritis. We may be able to precisely predict knee pain caused by osteoarthritis, by analysis of a model that includes a lesion in joint cartilage.
Prospective study was conducted in order to investigate the relationship between cognitive and behavioral disturbances and falls in dementia. Falls and fall-related fractures were studied in 154 ambulatory patients who were admitted to a geriatric intermediate nursing facility with a diagnosis of Alzheimer's type dementia (DAT) or mixed Alzheimer and vascular dementia (MIX). The Mini-Mental State (MMS) was used for the evaluation of cognitive status, and the Dementia Behavior Disturbance Scale (DBD) was used as a behavioral parameter. In order to evaluate problematic behavior in walking, a derivative scale (DBD-W) was developed from the DBD by choosing three items relevant to wandering. During the 3 months of observation, 61 patients fell more than once; 15 of them experienced fractures. The mean MMS scores were higher in non fallers, fallers who did not sustain fractures and those complicated with fractures, in that order, and the difference between the non fallers and fallers with fractures was statistically significant. When the subjects were divided into three subgroups on the basis of the MMS scores, there was a trend toward a higher ratio of fallers or those complicated with fractures in the subgroup with the lower MMS score. The DBD and DBD-W scores were not associated with falls or fractures, although fallers had a slightly higher DBD or DBD-W score than non fallers. These findings suggest that the risk of falling or fracture becomes higher with the advance of cognitive impairment in institutionalized ambulatory patients with DAT or MIX. The findings also suggest that behavioral disturbances are not necessarily associated with falls or fractures.
We report a case of an 82-year-old woman with polymyalgia rheumatica (PMR) associated with swelling and pitting edema of the lower extremities. The patient had been previously admitted because of PMR in 1990, but there was no history of swollen extremities. In July 1996, at another hospital, she was again diagnosed as having PMR on the basis of pain in the neck, shoulders and lower back. Administration of prednisolone was followed by improvement of the symptoms. Four months later, similar pain recurred and swelling of the lower extremities was noted. On admission, the erythrocyte sedimentation rate was 86mm/h, and C-reactive protein was 15.5mg/dl. Reviewing the previous treatment, it was ascertained that her clinical deterioration was due to premature reduction of the steroid dosage. The cause of the swelling of the lower extremities was unlikely to be heart, liver, kidney or endocrine disease. Prednisolone was increased from 2.5 mg to 10mg daily with marked improvement in all the symptoms including the swelling and pitting edema. In 1996, a study reported distal extremity swelling with pitting edema as a manifestation of PMR, which mostly developed concurrently with proximal symptoms or during relapses of PMR. The swelling responded poorly to non-steroidal antiinflammatory drugs but promptly to corticosteroids. The distal swelling was reported to be tenosynovitis and synovitis of the surrounding structures. The present case appears similar to that report. More studies of PMR need to be done.
An 80-year-old woman being treated with antihypertensive drugs developed eruption and itching of the skin. High fever and lymph node enlargement subsequently developed in spite of discontinuing all antihypertensive drugs, and she was admitted to our hospital. At the initial examination, multiple papules were noted over the entire body, and the skin showed thickening and lichenification with scratch marks. There was also generalized enlargement of the superficial lymph nodes. From these indings, her condition was diagnosed as chronic prurigo due to drug allergy. Laboratory tests showed inflammatory findings, anemia and a high serum level of IgE. Analysis of the surface marker of peripheral lymphocytes revealed no abnormalities. Bacteriologic cultures of blood revealed methicillin-resistant Staphylococcus aureus (MRSA). Histologic examination of the lymph nodes revealed chronic reactive lymphadenitis with a follicular pattern. She was strongly suspected of having MRSA septicemia, and so combination chemotherapy with vancomycin, minocycline and cefoperazone/sulbactam was started. However, 1 month after initiation of chemotherapy, the low-grade fever, eruption and moderate inflammatory findings persisted, and culture of the eruptions revealed MRSA. The prurigo was therefore considered to be the source of the septicemia, and daily application of diflucortolone ointment containing 3% acetic acid was started. Thereafter, the clinical and laboratory findings showed a rapid improvement. MRSA infections usually occur in compromised patients who are receiving antibiotics during prolonged hospitalization. The present case, who did not have any underlying disease, indicates that old-age is also an important factor for the development of MRSA septicemia.